Health policy making through operative actions: a case study of provider capacity reduction in a public safety-net system

This article describes and assesses the implications of policy decisions affecting health provider capacity in the Los Angeles County municipal safety-net health system from 1980 to 2000. Although never articulated in law or a county ordinance, the county pursued a sustained and discernable policy of cost reductions that affected capacity at King/Drew Medical Center from 1980 to 2000 without the input of beneficiaries or their advocates. Year after year, the county reduced personnel, supplies, and available beds either by reducing formal budgets or through operative actions of facility administrators that prevented the implementation of formally approved expenditures. This policy appears to have undermined the hospital system's mission of providing health services to at-risk populations with nowhere else to go. Decision making during the two decades under study revealed a decision-making pattern that challenged traditional models of policy decision making.

Effects of consumer and provider moral hazard at a municipal hospital out-patient department on Ghana's National Health Insurance Scheme

BACKGROUND

In 2003, Ghana introduced the national health insurance scheme (NHIS) to promote access to healthcare. This study determines consumer and provider factors which most influence the NHIS at a municipal health facility in Ghana.

METHOD

This is an analytical cross-sectional study at the Winneba Municipal Hospital (WHM) in Ghana between January-March 2010. A total of 170 insured and 175 uninsured out-patients were interviewed and information extracted from their folders using a questionnaire. Consumers were from both the urban and rural areas of the municipality.

RESULTS

The mean number of visits by insured consumers to a health facility in previous six months was 2.48 +/- 1.007 and that for uninsured consumers was 1.18 +/- 0.387(p-value<0.001). Insured consumers visited the health facility at significantly more frequent intervals than uninsured consumers (χ(2) = 55.413, p-value< 0.001). Overall, insured consumers received more different types of medications for similar disease conditions and more laboratory tests per visit than the uninsured. In treating malaria (commonest condition seen), providers added multivitamins, haematinics, vitamin C and intramuscular injections as additional medications more for insured consumers than for uninsured consumers.

CONCLUSION

Findings suggest consumer and provider moral hazard may be two critical factors affecting the NHIS in the Effutu Municipality. These have implications for the optimal functioning of the NHIS and may affect long-term sustainability of NHIS in the municipality. Further studies to quantify financial/ economic cost to NHIS arising from moral hazard, will be of immense benefit to the optimal functioning of the NHIS.

A two-dimensional equity proposal for self-sufficiency in municipal safety-net hospitals

This article advances a two-dimensional equity approach for self-sufficiency in municipal safety-net hospitals that will strengthen provider self-sufficiency and protect the safety-net mission of providing a dignified floor of health services to the most disadvantaged members of the society. The model responds to the failure of current delivery strategies to effectively cope with the changing market configurations in safety-net systems that have eliminated the possibility of cross-subsidization which has long been the mainstay of safety-net systems. The identified pathway to self sufficiency is made up of (1) a differential service delivery framework which includes a two-tier patient system, uniform standards of care and service levels, and the creation of a community health campus; (2) independent sector ownership; and (3) intergovernmental policy actions restricting ownership of safety-net hospitals to nonprofit entities. Although this model is explained by demonstrating potential application in safety-net hospitals, it is believed that the model is applicable in ambulatory care settings. Future work can focus on the construction of an ambulatory variation of the model and the empirical testing of the hospital and ambulatory models.

Affording what's free and paying for choice: comparing the cost of public and private hospitalizations in urban Kerala

OBJECTIVE

To assess the cost of public and private hospitalizations in urban Kerala and discuss policy implications of social disparities in the economic burden of hospital care.

METHODS

The NSSO survey on health care (1995-1996) for urban Kerala was analysed with regards to expenditure incurred by hospital episodes. Multilevel linear models were built to assess factors associated with levels of health expenditure.

FINDINGS

Hospital care involves paying admission fees in 68% of cases of hospitalizations (98% in private and 20% in public sector) in urban Kerala. Poor households and those headed by casual workers show significantly lower levels of health expenditure and a higher proportion of health-related loss of income than other social groups. Although there is significant expenditure in both sectors for these groups, hospitalization on free public wards is associated with lower expenditure than other options. Factors linked with higher expenditure are: duration of stay; hospitalizations on paying public wards and in the private sector; hospitalizations for above poverty line households and hospitalizations for chronic illnesses. Expenditure for services bought from outside the hospital is important in the public sector.

CONCLUSION

Hospitalization incurs significant expenditure in urban Kerala. Greater availability of free medical services in the public sector and financial protection against the cost of hospitalization are warranted.

Randomized clinical trial of a postdischarge pharmaceutical care program vs. regular follow-up in patients with heart failure

OBJECTIVE

To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure (HF).

METHOD

A randomized, prospective, open clinical trial in patients admitted for HF. The patients assigned to the intervention group received information about the disease, drug therapy, diet education, and active telephone follow-up. Visits were completed at 2, 6, and 12 months. Hospital re-admissions, days of hospital stay, treatment compliance, satisfaction with the care received, and quality of life (EuroQol) were evaluated; a financial study was conducted in order to assess the possible impact of the program. The intervention was performed by the pharmacy department in coordination with the cardiology unit.

RESULTS

134 patients were included, with a mean age of 75 years and a low educational level. The patients of the intervention group had a higher level of treatment compliance than the patients in the control group. At 12 months of follow-up, 32.9% fewer patients in the intervention group were admitted again vs. the control group. The mean days of hospital stay per patient in the control group were 9.6 (SD=18.5) vs. 5.9 (SD=14.1) in the intervention group. No differences were recorded in quality of life, but the intervention group had a higher score in the satisfaction scale at two months [9.0 (SD=1.3) versus 8.2 (SD=1.8) p=0.026]. Upon adjusting a Cox survival model with the ejection fraction, the patients in the intervention group had a lower risk of re-admission (Hazard ratio 0.56; 95% CI: 0.32-0.97). The financial analysis evidenced savings in hospital costs of euro 578 per patient that were favorable to the intervention group.

CONCLUSIONS

Postdischarge pharmaceutical care allows for reducing the number of new admissions in patients with heart failure, the total days of hospital stay, and improves treatment compliance without increasing the costs of care.

Health Economic Analysis of Fluoropyrimidine-Based Therapies of Colorectal Cancer from the Perspective of Statutory Sickness Funds

AIMS

1) to identify the treatment costs of different standard fluoropyrimidine-based therapies, i. e., the Mayo-Clinic and AIO/Ardalan regimens, under real-life conditions in settings routinely used for chemotherapy administration in Germany (inpatient, day-clinic or office-based oncologists) and 2) to investigate the cost implications of the routine use of capecitabine, an oral alternative for the treatment of metastatic colorectal cancer.

METHODS

We analysed the actual fee-listings of office based oncologists and projected the results to several hospital-based treatment settings and to oral treatment with capecitabine from the perspective of statutory sickness funds.

RESULTS

Office-based setting: the highest quarterly treatment costs of 9.874 were found for the AIO/Ardalan-regimen, followed by the Mayo-Clinic regimen, which incurred costs of 2.497. The cheapest treatment option was capecitabine with quarterly costs of 1.610. Day-clinic setting: the costs of the Mayo-Clinic protocol amounted to 2.036 in a municipal hospital and 8.455 in a university hospital. The respective costs for the AIO/Ardalan regime were 1.294 and 5.374. In-patient setting: the Mayo-Clinic protocol costs were 3.143 in a municipal hospital and 10.5609 in a university hospital. The respective costs found for the AIO/Ardalan-regimen were 1.998 and 6.717.

CONCLUSION

From a health economic perspective, substantial cost savings for health insurance may be realised if patients with colorectal carcinoma were treated in the office-based setting with capecitabine instead of a hospital-based treatment. Economic consequences would be positive for municipal hospitals (avoided losses) and negative for university hospitals. Further savings could be realised if drug prices in hospital and retail pharmacies were harmonized.

The role of U.S. public hospitals in urban health

Public hospitals in the United States play a key role in urban health. In many metropolitan communities, public hospitals maintain the health care safety net. Most urban public hospitals have evolved to not only provide care for the indigent but also to serve their communities in other ways, including serving as major providers for tertiary services such as trauma and those that support homeland security; serving as the foundation for primary care services; continuing to train a significant number of physician, nurses, and other medical personnel; and providing laboratories for clinical medical research. Federal budget cuts such as those in the Balanced Budget Act of 1997, recent state budget deficits, competition for Medicaid Managed Care, and the growth in the number of uninsured have led to a decline in revenues among urban public hospitals. To be better stewards of scarce resources, public hospitals have moved to reduce inpatient demand by adopting prevention strategies that are aimed at addressing the determinants of health, the complex interactions among social and economic factors, the physical environment, and individual behavior. These factors contribute to health status and offer opportunities to intervene and improve community health. Urban public hospitals, to be successful in the next stage of their evolution, need to learn to manage the "in-betweens"--partnering with governmental and nongovernmental entities to identify and work together on common health and safety issues. If public hospitals engage the community successfully, building trust and establishing new capability and capacity, urban public hospitals will survive, evolve, and continue their tradition of service.

A management information system to plan and monitor the delivery of health‐care services in government hospitals in India

Governments all over the world are getting increasingly concerned about their ability to meet their social obligations in the health sector. In this paper, we discuss the design and development of a management information system (MIS) to plan and monitor the delivery of healthcare services in government hospitals in India. Our MIS design is based on an understanding of the working of several municipal, district, and state government hospitals. In order to understand the magnitude and complexity of various issues faced by the government hospitals, we analyze the working of three large tertiary care hospitals administered by the Ahmedabad Municipal Corporation. The hospital managers are very concerned about the lack of hospital infrastructure and resources to provide a satisfactory level of service. Equally concerned are the government administrators who have limited financial resources to offer healthcare services at subsidized rates. A comprehensive hospital MIS is thus necessary to plan and monitor the delivery of hospital services efficiently and effectively.

Motor city blues

With its safety net hospital in peril, Detroit had a choice: fundamentally reform its public health system or watch it collapse. Cities nationwide face a similar dilemma.

Cost analysis of pneumonia treatment in the Philippines

The objectives of this study were to describe the cost distribution of pneumonia treatment in tertiary hospitals in the National Capital Region (NCR) and to identify variations in costs in order to provide basic information to the Philippine Health Insurance Corporation (PHIC) for quality assurance and policy development. This study focuses on 3861 reimbursement claims, which come from 22 government and 38 private tertiary hospitals. Wide variations of cost existed among the hospitals and among the inpatients. Medicine was the leading expenditure in total costs (38%), second was examinations (27%), third was beds (22%) and the last was doctors fees (13%). The same ranking ocurred for reimbursement by PHIC. The private hospitals were more expensive than the government hospitals, but also more efficient in the length of hospitalization. The member patients spent more and were reimbursed more for clinical practice than the dependent patients. However, there was no difference in the length of hospitalization between member and dependent patients. There was no difference in the length of hospitalization and expenditure between Government Service Insurance System (GSIS) in 1997 and Social Security System (SSS) patients. Clinical guidelines should be effectively implemented and PHIC should contribute more to reduce existing variations, improve cost-effectiveness and the quality of clinical practices.

[Costs of digestive endoscopy in a level II university hospital]

OBJECTIVES

To establish the criteria that should be considered when analyzing the cost of digestive endoscopy and to determine how the variables studied influence the final results, as well as to determine the relative value unit (RVU) per endoscopic procedure.

MATERIAL AND METHOD

Clinical management study relating the cost of endoscopic procedures with their complexity, healthcare activity and direct and indirect countable costs. The endoscopic procedures performed from 2000-2001 (4,982 procedures) were analyzed. We determined the staff costs according to the hours devoted to endoscopic activity, the procedures performed and their complexity, non-amortizable and amortizable materials acquired in the study period, and the cost and amortization of apparatus and equipment.

RESULTS

The biannual cost was 392,892.60;. Staff costs were 63%, apparatus and equipment 15%, structural costs 13%, pharmacy 6%, materials 2% and amortizable materials 1%. The least expensive procedure was diagnostic gastroscopy (60.56;) and the most expensive was therapeutic endoscopic retrograde cholangiopancreatography (277.06;). The RVU cost was 52.58;.

CONCLUSIONS

Calculation of the cost of any medical procedure should take into account the strict application of direct and indirect costs. In our environment, the cost of endoscopy is lower than might be expected, mainly because the cost of amortization of apparatus and equipment and staff costs were low. Calculation of the complexity index is of considerable clinical and healthcare value. Determination of the RVU is a key element in establishing the cost of a procedure and in relating this cost with other costs, allowing its application as well as comparison among different investigations, services and centers.

Costs of publicly provided maternity services in Rosario, Argentina

OBJECTIVE

This study estimates the costs of maternal health services in Rosario, Argentina.

MATERIAL AND METHODS

The provider costs (US$ 1999) of antenatal care, a normal vaginal delivery and a caesarean section, were evaluated retrospectively in two municipal hospitals. The cost of an antenatal visit was evaluated in two health centres and the patient costs associated with the visit were evaluated in a hospital and a health centre.

RESULTS

The average cost per hospital day is $114.62. The average cost of a caesarean section ($525.57) is five times greater than that of a normal vaginal delivery ($105.61). A normal delivery costs less at the general hospital and a c-section less at the maternity hospital. The average cost of an antenatal visit is $31.10. The provider cost is lower at the health centre than at the hospital. Personnel accounted for 72-94% of the total cost and drugs and medical supplies between 4-26%. On average, an antenatal visit costs women $4.70. Direct costs are minimal compared to indirect costs of travel and waiting time.

CONCLUSIONS

These results suggest the potential for increasing the efficiency of resource use by promoting antenatal care visits at the primary level. Women could also benefit from reduced travel and waiting time. Similar benefits could accrue to the provider by encouraging normal delivery at general hospitals, and complicated deliveries at specialised maternity hospitals.

Pneumococcal vaccination: analysis of opportunities in an inner-city hospital

BACKGROUND

Adult pneumococcal vaccination rates for persons at risk of developing pneumococcal disease remain below desired levels. Various sites within the hospital (inpatient medicine wards [IMWs], general medicine clinics [GMCs], and emergency departments [EDs]) have been suggested as venues for administering vaccination. The cost-effectiveness of such sites for delivery of pneumococcal vaccination is not known.

OBJECTIVE

To compare the potential coverage of at-risk patients and cost of pneumococcal vaccination delivered in an ED, GMC, and IMWs.

METHODS

We studied a retrospective cohort of 300 patients with pneumococcal bacteremia who had been hospitalized at Cook County Hospital, an inner-city Chicago public teaching hospital, from January 1994 through December 1998. We measured the presence of risk factors, as defined by the Centers for Disease Control and Prevention, for developing pneumococcal disease prior to index admission for bacteremia; patient use of ED, GMC, and IMWs from 4 weeks to 5 years before index admission; size of target population for vaccination in each site; and cost benefit of a pneumococcal vaccination strategy at each site.

RESULTS

In the 4 weeks to 5 years before index admission, risk factors were present in 209 patients; 182 (87.1%) of the 209 had been in the ED, 104 (49.7%) in an IMW, and 64 (30.6%) in a GMC. The ED showed the greatest potential vaccine coverage, at a cost savings in a best-case scenario; the IMWs showed the best cost-benefit ratio but would provide access to fewer at-risk patients; and a program in the GMC would reach the fewest at-risk patients, with a cost-benefit ratio similar to that of the ED.

CONCLUSIONS

The ED in an inner-city hospital has the potential to vaccinate more patients at risk of pneumococcal bacteremia than a GMC or IMWs, and may do so at a cost savings. A prospective evaluation of such a strategy is warranted.

Low cost autologous peripheral blood stem cell transplantation performed in a municipal hospital for a patient with plasma cell leukaemia

Autologous peripheral blood stem cell transplantation (PBSCT) is a costly procedure. In India, the cost varies from US$20000 to 25000 and most patients cannot afford it. Using several cost-cutting measures, we were able to treat a patient with plasma cell leukaemia by autologous PBSCT. A 42-year-old-male presented with plasma cell leukaemia. He was treated with VAD therapy, followed by high-dose cyclophosphamide and granulocyte colony-stimulating factor (G-CSF) for mobilization of peripheral blood stem cells. The patient was conditioned with high dose melphalan, followed by autologous PBSCT. The procedure was performed in a municipal hospital in which there was no prior experience with stem cell transplantation. Costs were reduced by: (i) using oral medication whenever possible; (ii) having a relative of the patient prepare his food under medical guidance; (iii) starting G-CSF on day 7 rather than on day 1; (iv) short-term storage of the PBSC in an ordinary refrigerator at 4 degrees C without cryopreservation; (v) infusing a large number of CD34+ cells, which shortened the time to engraftment; (vi) delegating many of the functions of a marrow transplant nurse to a resident physician. The cost of transplantation was thereby reduced to about US$ 6000, with successful engraftment by day +13. The patient remained in remission for 7 months, after which he relapsed and was treated with chemotherapy and electron beam radiation to the skin.

"Voluntary" user fees in Buenos Aires hospitals: innovation or imposition?

Voluntary user fees in hospitals in Buenos Aires, which operate outside official controls, have not featured in other studies of health care in Argentina. After providing a historical overview of different hospital funding sources, the authors focus on the activity of cooperadoras--the organizations responsible for levying voluntary fees. Using detailed data from two case-study hospitals and more general financial sources, they assess the importance of these fees, identifying sharp variations between different hospitals, serious problems of under-reporting, and potential abuses. The authors also examine the means by which fees are levied and the degree of coercion involved. Voluntary fees are not a particularly successful funding strategy: the income they generate is variable; they are almost entirely unregulated; and they sometimes conflict with other, more legitimate funding sources. Most importantly, their voluntaristic aspect is largely notional: most patients are heavily pressured to make payments. The main motivation for continuing with voluntary fees is to avoid the political fallout that would probably result from introduction of a formal user fees policy.

Case management: an evaluation at Childrens Hospital Los Angeles

This prospective, quantitative, and qualitative evaluation of the case management program at CHLA clearly demonstrated the value of professional service coordination of care for children with complex, special health needs. Most specifically, the program documented improvement in three discrete areas of evaluation: 1. Financial, with decreased unnecessary expenditures and increased revenue. 2. Patient satisfaction, documented with validated questionnaires. 3. Clinical process improvement, using quantifiable clinical outcomes. At the very least, case management is an extremely valuable service in the present managed health care environment, and may in fact be indispensable.

Reengineering the Lithuanian healthcare system: a hospital quality improvement initiative

A tertiary-level academic hospital in Kaunas, Lithuania, adopted a continuous quality improvement (CQI) management paradigm from June 1996 through July 1997 in response to new political, economic, and social environments. This article presents an overview of the hospital's strategy, initial steps, and main accomplishments, as well as mitigating factors that arose in its quest to manage its own resources. Because historical influences are key to understanding the Lithuanian healthcare system, this discussion includes pre- and post-independence dynamics that caused a multidisciplinary hospital management team to choose a CQI approach that targets organizational and professional structures for change. In addition, it identifies environmental factors, internal and external to the hospital organization, that influence the continued development and sustainability of these healthcare management reform efforts.

[Cost analysis of dialysis treatment at the Odense University Hospital and the Sønderborg Hospital]

The major purpose of this paper is to investigate the treatment costs of dialysis treatment by modality. In this study Odense University Hospital (OUH) and Sønderborg Hospital were chosen as cases. The costs of haemodialysis (HD) treatment are estimated to DKK 341-392,000 per patient during the first year, and DKK 328-379,000 per year the following years. The costs of continuous ambulatory peritoneal dialysis (CAPD) treatment are estimated to DKK 262-291,000 per patient during the first year, and DKK 251-277,000 per year the following years. The costs of CCPD (peritoneal dialysis with the aid of a machine), treatment are estimated to DKK 312-325,000 per patient during the first year, and DKK 296-308,000 per year the following years. The treatment costs of HD are lower than expected, while the treatment costs of PD are higher than expected. As a result of this the differences in treatment costs (HD versus PD) are much lower than expected, DKK 130,000 at the most.

[Substantiation of the choice of technical means in reduction of implementation costs of the project "Full automation of a central municipal hospital"]

A way of reducing the cost price of hospital automation is proposed. It is not necessary for it to update the whole equipment, but only a small part--the workstations used by programmers for their work, which support the stability of hospital automation; the working places of operators should be kept without modifications, but to allot them properties to inherit a potency and modernity of the purchased equipment; for this purpose they should be equipped with virtual machines copying properties of workstations being arrange in accordance with the pyramidal structure. A UNIX which represents a multi-user, multitask operational operative system providing an access on several pseudoterminals is simultaneously installed on the PENTIUM 100/133 workstation. A graphic terminal of the AMR "UnTerminal" firm (USA) is proposed for use as working places. Their advantage is that they have a special adapter connected directly to the bus of PC extension. Each user is allotted a video adapter, a keyboard controller, sequential and parallel interfaces for connection of the printer and manipulator. Each working place supports multitasking and it can be equipped with a printer, a "mouse" or modem. The image is transmitted on work places with a very high velocity-77 mehabits/sec that supports not only a text mode, but also VGA or SVGA graphics. Certainly, graphic terminals are more expensive than text terminals, but their capacities are similar to those of the main computer, here, the workstation. They may be located from the main computer at a distance of up to 75 meters or more and do not require adjustment during their installation.

Quality improvement in an integrated urban healthcare system: a necessary journey

Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These "safety-net" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key "lessons learned" may guide others.

Medical-resource use for suspected tuberculosis in a New York City hospital

OBJECTIVE

To compare resource use by diagnostic outcome among hospital admissions during which tuberculosis (TB) was suspected.

DESIGN

Retrospective study based on chart review and microbiology laboratory data.

SETTING

The department of medicine in a municipal hospital serving central Brooklyn, New York.

PARTICIPANTS

We identified all adult admissions in 1993 during which TB was suspected. We assigned each admission to one of four mutually exclusive groups defined by the results of microbiological tests (acid-fast bacilli [AFB] smear and culture): culture-positive and smear-positive (C+S+); culture-positive and smear-negative (C+S-); culture-negative and smear-positive (C-S+); or culture-negative and smear-negative (C-S-). Each admission was divided into two separate periods to which the utilization of medical resources was assigned: the diagnostic and the postdiagnostic periods, which were separated by the date of receipt of the first definitive culture report.

RESULTS

Data on 519 admissions (93 C+S+; 57 C+S-; 30 C-S+; and 339 C-S-) were analyzed. Although C+S+ were more likely than other groups to have an admitting diagnosis of TB, approximately one quarter of the admissions without TB (C-S+, C-S-) were admitted with the principal diagnosis of TB. For the four groups, C+S+, C+S-, C-S+, and C-S-, the respective rates of TB isolation and anti-TB treatment, and median lengths of isolation were 98%, 87%, and 34 days; 74%, 74%, and 7 days; 83%, 83%, and 15 days; and 44%, 29%, and 0 days. During the diagnostic period, the rate and length of isolation were similar in the AFB-smear-positive groups (C+S+ and C-S+). We estimated that admissions without culture-proven TB (C-S+ and C-S-) accounted for 3,174 (36%) of the 8,712 days of TB isolation expended and for 65% of the 16,671 days of anti-TB treatment. The vast majority of this resource consumption (2,737 [86%] of 3,174 days of isolation) occurred during the diagnostic period before a definitive culture result was known.

CONCLUSIONS

Our results suggest that prolonged diagnostic uncertainty and misclassification of cases due to false-positive and false-negative smears are associated with substantial medical-resource consumption. New diagnostic modalities that reduce the period of diagnostic uncertainty could reduce the utilization of resources later found to be unnecessary.

Upstairs downstairs: vertical integration of a pediatric service

BACKGROUND

The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources.

OBJECTIVE

To describe the development of a new vertically integrated pediatric service at an inner-city municipal hospital and to test whether its adoption was associated with the use of fewer inpatient resources.

DESIGN

A descriptive analysis of the rationale, goals, implementation strategies, and structure of the vertically integrated pediatric service combined with a before-and-after comparison of in-hospital resource consumption.

METHODS

A before-and-after comparison was conducted for two periods: the period before vertical integration, from January 1989 to December 1991, and the period after the adoption of vertical integration, from July 1992 to December 1994. Four measures of inpatient resource use were compared after adjustment for case mix index: mean certified length of stay per case, mean number of radiologic tests per case, mean number of ancillary tests per case, and mean number of laboratory tests per case. Difference-in-differences-in-differences estimators were used to control for institution-wide trends throughout the time period and regional trends in inpatient pediatric practice occurring across institutions. Results. In 1992, the Department of Pediatrics at the Albert Einstein College of Medicine reorganized the pediatric service at Jacobi Medical Center, one of its principal municipal hospital affiliates, into a vertically integrated pediatric service that combines ambulatory and inpatient activities into four interdependent practice teams composed of attending pediatricians, allied health professionals, house officers, and social workers. The new vertically integrated service was designed to improve continuity of care for patients, provide a model of practice for professional trainees, conserve scarce resources, and create a clinical research infrastructure. The vertically integrated pediatric service augmented the role of attending pediatricians, extended the use of allied health professionals from the ambulatory to the inpatient sites, established interdisciplinary practice teams that unified the care of pediatric patients and their families, and used less inpatient resources. Controlling for trends within the study institution and trends in the practice of pediatrics across institutions throughout the time period, the vertical integration was associated with a decline in 0.6 days per case, the use of 0.62 fewer radiologic tests per case, 0.21 fewer ancillary tests per case, and 2.68 fewer laboratory tests per case.

CONCLUSIONS

We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources.

Continuous quality improvement decreases length of stay and adverse events: a case study in an interventional cardiology program

A study was performed to assess the effectiveness of continuous quality improvement in achieving a better quality of care for patients undergoing coronary interventions. Increasing utilization of new coronary interventional devices has incurred a higher incidence of complications, prolonged hospital stay, and related costs. Using a clinical information system, we adopted continuous quality improvement to control the incidence of complications and postprocedural length of stay. Multiple regression analysis and a matched case-control study were performed to detect complications related to postprocedural length of stay and their causes among 342 patients. The results led to the modification of the postprocedural heparin anticoagulation protocol, which was followed by the introduction of a ticlopidine-based poststent anticoagulation regimen. Two sequential groups of patients (n = 261, n = 266) were selected to compare postprocedural length of stay and frequency of complications with those for the first group. Adjustments were made for patients and procedural characteristics through stratification and multiple regression methods. Blood transfusion was the most important predictor of prolonged hospital stay (partial R2 = 0.26, P < 0.01). A high level of postprocedural anticoagulation and intracoronary stent use were significantly associated with blood transfusion (P = 0.01, P = 0.02, respectively). The comparison among the three groups showed that heparin protocol change reduced only postprocedural length of stay (P < 0.001) for patients without stents, whereas the stent change in anticoagulation protocol significantly reduced both transfusion and hospital stay for patients with stents (P < 0.001, P < 0.05, respectively). Continuous quality improvement based on clinical information is promising to control both complications and hospital costs. Physician involvement is necessary throughout the process.

Quality improvement, housestaff, and the role of chief residents

PURPOSE

Little is known about the role of chief residents in utilizing and promoting continuous quality improvement (CQI) and quality assurance (QA) methods with housestaff. The purpose of this study was to ascertain how chief residents could be involved more formally in improving the quality of care in a major public teaching hospital.

METHOD

Fourteen chief residents on the major services at Boston City Hospital participated in early 1994 in either a focus group or an individual interview. Data were analyzed qualitatively using a grounded-theory methodology.

RESULTS

The chief residents saw themselves as central to service delivery, teaching, and administration of the hospital. While they identified many role conflicts and system obstacles to providing quality patient care, they were uniformly positive about the contributions they made to Boston City Hospital and its patient population. They distinguished between formal QA and the major improvements they made on their services. Very few knew much about CQI methodology.

CONCLUSIONS

Given increasing competition as a result of the rapid growth in managed care, hospitals with residency programs, especially public hospitals, must integrate their teaching programs into patient care models. Chief residents and the housestaff they supervise receive little training in CQI methods. As housestaff will be training and practicing in an environment where costs and quality will be intertwined, chief residents, with their credibility, contacts, and concern, can help incorporate CQI into the environment of graduate medical education.

Sick & tired. Reinventing the public health care system may be its only hope for survival

As the public health care system continues to slide, the poor are looking elsewhere for care. Is there still a way to help them without endangering the entire system? Those on the front lines say yes--well, at least maybe--if steps are taken now. Fresh ideas, new partnerships--everything is up for grabs in today's turbulent times.